OFFICIAL. NHS 111 Clinical Governance Tool Kit: Model documents to support good practice

Transcription

1 NHS 111 Clinical Governance Tool Kit: Model documents to support good practice

2 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Trans. & Corp. Ops. Commissioning Strategy Finance Publications Gateway Reference: Document Purpose Guidance Document Name Author Publication Date Target Audience Additional Circulation List Description Cross Reference Superseded Docs (if applicable) Action Required NHS 111 Clinical Governance Tool Kit Dr Ossie Rawstorne, NHS 111 National Medical Advisor and Dr Helen Thomas, NHS 111 South West Clinical Lead 16 March 2015 CCG Clinical Leaders, CCG Accountable Officers, Provider Clinical Leads #VALUE! The purpose of this document is to assist commissioners of NHS 111 to develop clinical governance arrangements that support the delivery of a safe, clinically effective service which provides a positive experience for users. It supplements the guidance provided within the NHS 111 Commissioning Standards document. NHS 111 Commissioning Standards n/a n/a Timing / Deadlines (if applicable) Contact Details for further information Document Status 0 n/a Dr Ossie Rawstorne, NHS 111 National Medical Advisor NHS England Skipton House 80 London Road SE1 6LH This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. NB: The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

3 NHS 111 Clinical Governance Tool Kit: Model documents to support good practice Version number: 1.0 First published: March 2015 Prepared by: Dr Ossie Rawstorne, NHS 111 National Medical Advisor and Dr Helen Thomas, NHS 111 South West Clinical Lead Classification: OFFICIAL The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

4 Contents Contents Purpose Introduction NHS 111 Commissioning Standards Model Documents Local Clinical Governance Lead Job Description and Person Specification Regional Clinical Governance Lead Job Description and Person Specification Local Clinical Governance Group Terms of Reference Regional Clinical Governance Group Terms of Reference Provider Quality Monitoring Report Template Audit Report Template Call and End to End Review Template Description of the National Learning Log Local Clinical Governance Lead Monthly Report Template Regional Clinical Governance Lead Monthly Report Template NHS Pathways Intelligent Data Tool

5 1 Purpose The purpose of this document is to assist commissioners of NHS 111 to develop clinical governance arrangements that support the delivery of a safe, clinically effective service which provides a positive experience for users. Guidance on clinical governance is provided in the NHS 111 Commissioning Standards document. 2 Introduction Commissioners of NHS 111 across England have, from the outset, appreciated the importance of a robust clinical governance structure which is central to the provision of the service. The form and function of the NHS 111 Clinical Governance Framework was developed by Dr Nicholas Reeves and articulated in the original service specification in Following concerns about the quality and safety of NHS 111 during 2013, Dr Mike Durkin, Director of Patient Safety, NHS England led a review into the quality and safety of the service 1. One part of this review, led by Dr Helen Thomas, investigated the clinical governance arrangements of the service and highlighted their value. Many of the documents in this tool kit were collected during the visits she and other colleagues made as part of this review. The aim of these documents is to support local commissioners in assuring the quality of the service and to share learning across the country. The Tool Kit contains the following documents: 1 5

6 Local Clinical Governance Lead Job Description Regional Clinical governance Lead Job Description Local Clinical Governance Group Terms of Reference Regional Clinical Governance Group Terms of Reference Provider Quality Monitoring report template Audit report template Call and end to end review template Description of the National Learning log Local Clinical Governance lead monthly report template Regional Clinical Governance lead monthly report template 3 NHS 111 Commissioning Standards The guidance below is contained within Annex C of the commissioning standards document. Clinical Governance Guidelines A good clinical governance process is required to ensure a safe, high quality service that shares good practice, evidences learning and strives for continuous quality improvement. The following is suggested good practice for NHS 111 clinical governance: 1. The appointment of a local NHS 111 clinical governance lead (CGL). This lead should be appropriately skilled and trained for the role. The CGL role involves the development of relationships across the whole urgent care network and the individual should be clinically credible in order to work effectively in this complex environment The CGL will be responsible for holding the provider to account for clinical standards The CGL must have clearly defined links to the regional and national NHS 111 clinical governance structures A minimum expectation is for the lead to have a day a week to dedicate to this role 2. A local clinical governance group, under strong clinical leadership and with clear lines of accountability to the commissioners of the NHS 111 service, working alongside and closely with the contracting team. The local governance group should bring together the NHS 111 service itself with all the NHS and social care providers 6

7 to whom patients may be referred, enabling all to develop a real sense of ownership of their local service 3. Clarity about lines of accountability within the NHS 111 service 4. A policy setting out the way in which adverse and serious incidents will be identified and managed, ensuring that the clinical leadership of the NHS 111 service plays an appropriate role in understanding, managing and learning from these events 5. Clear and well-publicised routes for both patients and health professionals to feedback their experience of the service, ensuring prompt and appropriate response to that feedback with shared learning between organisations 6. Regular surveys of patient and staff experience (using both qualitative and quantitative methods) to provide additional insight into the quality of the NHS 111 service 7. Regular review by the CGL of the quality of the calls, with the involvement of other partner organisations, especially where their outcomes have proved problematic 8. Provision of accurate, appropriate, clinically relevant and timely data about the NHS 111 service to ensure that it is meeting the NHS 111 Commissioning Standards 7

8 4 Model Documents The following documents are suitable for adoption by commissioners in developing their clinical governance arrangements. They are not intended to be proscriptive and can be modified to meet local needs or used as a benchmark to test locally developed documents. 4.1 Local Clinical Governance Lead Job Description and Person Specification xxxxxxxx NHS111 Job Title Nominal Location / Base Remuneration Responsible to Fixed Term Job Description: NHS 111 Clinical Lead xxxxx CCG(s) NHS 111 Clinical Lead TBC xxxxxxx CCG(s) Urgent Care Lead Job Purpose The NHS111 Clinical Lead will provide clinical leadership and strategic oversight of the NHS111 Service in terms of its clinical safety, governance and effectiveness on behalf of xxxxx CCG(s) The role will be hosted by xxxxx CCG(s). The Clinical Lead will Chair the xxxxx NHS 111 Clinical Governance Committee. Through this committee they will provide assurance on safe and sustainable clinical governance processes within the NHS 111 service. They will ensure robust feedback and reporting processes are in place, that feedback processes are operating as intended and that any clinical issues are reviewed and addressed as necessary. The clinical lead will offer clinical expertise in relation to NHS 111 to the local urgent care lead(s) and represent xxxxx CCG(s) at regional clinical governance forums. They will provide regular monthly progress reports to the NHS 111 Regional Clinical Lead and to other stakeholders as required. Main Duties 1. To provide strong clinical leadership and support for NHS 111 within the xxxxx CCG(s) and urgent care commissioning team 2. Undertake clinical engagement with health professional, GP consortia and other relevant stakeholders to ensure wide understanding of the NHS 111 service 3. Engage with other stakeholders and agencies as appropriate 4. Provide a healthy challenge to NHS 111, CCG(s) and urgent care systems with the common aim of improving patient care and patient and staff experience 5. To be integrally involved in all aspects of NHS 111 xxxx CCG(s) and urgent care decision making including the scrutiny of data and clinical outcomes 6. Chair the xxxx CCG(s) NHS 111 Clinical Governance Committee 7. Support the development and maintenance of a robust Directory of Services (DoS) and clinical pathways to underpin the service 8. To have sufficient organisational and inter-organisational support to be able to assure the quality of the clinical governance of the local NHS 111 service 9. Support and develop patient, public and professional feedback processes 8

9 10. To lead Call Reviews and End to End reviews of the patient pathway 11. To provide monthly updates using an agreed format and content to the regional CG lead and attend regional NHS 111 Clinical Governance meetings as required 12. To provide clinical leadership as part of any future re-procurement process Communications and Working Relationships The post holder will be expected to communicate directly and regularly with all key stakeholders including: NHS 111 Regional Clinical Governance Lead Xxxxx CCG(s) NHS 111 Lead Commissioner xxxxxxx CCG(s) urgent Care Leads and Quality Team Urgent Care Working Groups Professional stakeholders particularly the emergency ambulance service and GP Out of Hours services Other key stakeholders as required including the public Person Specification Current unrestricted registration with relevant professional body Understanding of, or interest in developing, clinical assessment and management of patients flows Excellent communications skills, preferably with media experience Sound understanding of clinical governance Good leadership skills with the ability to influence and negotiate with tact and diplomacy The ability to analyse complex issues, identify potential solutions and reach sound conclusions Clear commitment to delivering quality and patient focused services Personal Development and Appraisal The post-holder should have equitable access to NHS xxxx staff development opportunities and career progression. The post should be appropriately appraised and form part of the post holder s annual appraisal. Clinical and Corporate Governance The post holder will ensure compliance with employer policies, procedures and clinical guidelines. General This job description is intended as a guide to the principle duties and responsibilities for the post. Adaptation and evolution will be an essential characteristic as the programme develops. 9

10 4.2 Regional Clinical Governance Lead Job Description and Person Specification Job Title Nominal Location / Base Remuneration Responsible to Fixed Term xxxxxxxx NHS111 Programme Job Description: xxxxxxx Regional Clinical Lead NHS England xxxxxxx Area Team Medical Director Job Purpose The NHS111 Regional Clinical Lead will provide clinical leadership and a strategic oversight of the NHS111 Service in terms of its clinical safety, governance and effectiveness within the xxxxxx Region. Providing assurance on the continual development of robust, safe, and enduring clinical governance processes across each NHS service delivery area. The role will be hosted by the NHS England xxxxxxx Area Team s Medical Director, working as part of the NHS xxxxxx CCG NHS 111 Lead Commissioning Team. The Regional Clinical Lead will Chair the Regional Quality Assurance Committee with representation from each CCG s NHS111 Clinical Lead within the Footprint area and support from their Footprint Managerial Lead and the Lead Commissioning Core Team. To ensure robust feedback and reporting processes are in place and that, feedback systems are operating as intended and that any clinical issues are reviewed and addressed as is required. At a national level the Clinical Lead will offer clinical expertise in relation to NHS 111 and represent the xxxxxxx Region at regional and national forums as needed. Engaging at a national Level with other Clinical leads and NHS England leads as required; providing regular progress reports to the NHS 111 national medical advisor and other stakeholders. Main Duties 1. To be a member of the National Clinical Leads Group (NCLG) for NHS 111, acting as a conduit for dissemination of information to clinical colleagues as appropriate 2. Provide strong clinical leadership and support for NHS To put in place an agreed clinical work plan signed off and monitored via the Programme Board 4. To chair the XXX NHS111 Regional Clinical Quality Assurance Committee (CQAC) providing clinical input to all aspects of its activity; ensuring active clinical involvement in all areas relating to NHS111, in particular the development of links to the local Urgent Care Working Groups (UCWGs) through the CCG Clinical Leads. 5. To oversee call and End to End review systems 6. To oversee the robust monitoring of all level 4/5 incidents, where appropriate involvement or oversight in any end-to-end call reviews undertaken at the request of CCG CLs by Stability Partners. 7. To oversee via the Clinical Leads HPF feedback processes to identify any trends or themes and ensure appropriate action is taken to remedy issues. 8. To ensure links at strategic level with the Stability Partners and CCGs to implement clinical change e.g. learning from incidents, DoS and NHS Pathways developments and other highlevel impact operational issues. 9. Ensure the dissemination of outputs from the footprint CQAC to relevant stakeholders, especially local Urgent Care Working Groups and the wider public and stakeholders 10

11 Main Duties (cont.) 10. To be a member of the Provider Engagement Group (PEG) as the regional team clinical representative to ensure appropriate feedback and communication as part of the agreed governance process 11. Provide a healthy challenge for NHS111 across the Region and of urgent care systems with the common aim of improving patient care, experience and staff experience. 12. Undertake clinical engagement with health professionals and relevant stakeholders to ensure wider clinical engagement with the NHS111 Service within the Footprint. 13. To support and provide leadership to the footprint clinical Leads and via those leads to each individual CCG clinical lead across the region 14. Undertake where required, regular and appropriate mentoring and mentorship to ensure a strong individual performance and team relationship. 15. To develop and participate in NHS 111 education and learning events for CCG clinicians to promote wider understanding and engagement 16. To provide clinical leadership as part of any future re-procurement process 17. To support the National Clinical Lead as may be required 18. To oversee the preparation of all regional clinical reports required by the national team. Communications and Working Relationships The post holder will be expected to communicate directly and regularly with all key stakeholders including: National Medical Advisor xxxxxxx NHS111 Programme Board xxxxxxx NHS111 Lead Commissioner Core Team Other xxxxxx NHS111 Footprint Clinical Leads Footprint Managerial Lead(s) NHS111 Stability Partner(s) Provider Engagement Group NHS111/urgent care teams across the Footprint area Other key stakeholders as required, including the public NHS England Central Team /NHS England Area Team(s) Person Specification Current unrestricted registration with relevant professional body with experience of working strategically; Understanding of, or interest in developing, clinical assessment and management of patients flows Excellent communications skills, preferably with media experience; Sound understanding of clinical governance; The ability to understand and work in a politically sensitive environment; Good leadership skills with the ability to influence and negotiate with tact and diplomacy; The ability to analyse complex issues, identify potential solutions and reach sound conclusions; Clear commitment to delivering quality and patient focused services Appraisal The post should be appropriately appraised and form part of the post holder s annual appraisal. Clinical and Corporate Governance The post holder will ensure compliance with employer policies, procedures and clinical guidelines. General This job description is intended as a guide to the principle duties and responsibilities for the post. Adaptation and evolution will be an essential characteristic as the programme develops. 11

12 4.3 Local Clinical Governance Group Terms of Reference Terms of Reference for NHS 111 Clinical Governance Group Author Project Sponsor Clinical Lead Manager Lead Version no. Change History Version Date Author Comment Version control Status Approved for submission to xxxxx Board given by: Issue Xxxxx Board sign off given by: 1. Introduction These Terms of Reference (ToR) set out the purpose, membership and reporting arrangements for XXX Clinical Commissioning Group NHS 111 Clinical Assurance Committee. 2. Purpose 2.1 To ensure robust and measurable systems are evident within the XXX CCG NHS 111 commissioned service with specific emphasis on: The NHS 111 call handling including: Clinical triage and assessment of patient s clinical need Determining the most appropriate course of action and advice Referral processes to clinical advisors and local providers of care information sharing The whole patient pathway for service users accessing the service including the interfaces and relationships with partner providers 2.2 To develop a clinical governance and assurance framework that ensures the delivery of national and local guidance in relation to the NHS 111 service making certain good governance occurs between organisations and details the mechanisms by which the care of patients is safeguarded across the whole patient pathway. elation to the NH 12

13 2.3 To provide a forum and facilitate partnership working across the healthcare economy enabling a whole system approach to be adopted in shaping the model of urgent care in XXX CCG 2.4 To review and monitor the arrangements and clinical safety of the Clinical Operational Gateway (COG) access line for professionals 2.5 The group does not replace current forums within partner organisations, but acts to ensure good clinical governance links exist between those organisations. 3. Responsibilities General 3.1 To establish systems and review key performance indicators for assuring the quality, patient safety and patient experience of the NHS 111 service in relation to identified pathways including the provision of clinical scrutiny and overview of end to end pathways. 3.2 To monitor and review clinical risk management processes including actions taken to mitigate identified risks to ensure that the clinical integrity of the service remains resilient. 3.3 To review business continuity arrangements relating to the provision of 111 services 3.4 To review the recruitment, selection, training and professional development processes for NHS 111 call-takers and clinical advisors. To monitor the ongoing implementation of these training and professional development programmes. Learning from experience 3.5 To ensure robust processes are in place to recognise, report and investigate serious untoward incidents, complaints, near miss incidents and SUIs in accordance with national guidance. 3.6 To monitor and review action plans in relation to reported patient safety incidents, complaints and feedback from health care professionals ensuring that whole systems learning is achieved. 3.7 To undertake aggregated analysis of incidents, complaints and feedback to ensure trends and themes identified are subject to action planning and that a programme of continuous quality improvement is put in place. 3.8 Review patient experience through monitoring of 111 PALS information and satisfaction surveys. 3.9 Review patient experience by listening to 111 calls selected at random, as a result of complaints/incidents and in relation to themes selected by the CAC eg.calls from nursing homes Audit and Policy Development 3.10 To agree, monitor and seek assurance of the effectiveness of clinical audit programmes implemented within the NHS 111 commissioned service and across partner agencies to include interfaces of care To, receive, review and disseminate evidence based research and policy documents relevant to the NHS 111 service To develop, review and agree policies, protocols and guidelines, in light of local and national guidance, to ensure a safe patient pathway for patients using the NHS 111 service. 4. Membership 4.1 The membership is set out at Appendix A. 4.2 Other stakeholders may be invited to attend for specific items with the prior agreement of the Chair. This might also include representatives from independent contractors, community dental and optometry services. 13

14 5. Quorum 5.1 The Committee is quorate when four members are present. If such a quorum is not present within ¼ hour of the appointed time or if during the meeting ceases to be present, the meeting will stand adjourned. 6.Frequency of Meetings 6.1 Meetings shall be held monthly or otherwise as indicated by the programme and/or progress of work. 7. Conduct of Meetings 7.1 All questions arising will be decided by a simple majority of those present. In the case of equality of votes, the Chair will have a casting vote. 7.2 Minutes shall be kept and the Secretary shall record the proceedings and resolutions. 7.3 Agendas will normally be issued at least seven days prior to the meeting. Requests for items to be included on the agenda should be sent to the Chair at least ten days before the meeting. 7.4 Should an item need to be raised on the day, this can be covered under Any Other Business, subject to there being available time. 7.5 If separate papers require circulation, these should, wherever possible, be issued with the agenda. This is intended to enable the members to have the opportunity to read information in advance. 7.6 Notes from meetings will be produced and issued by the Chair. These will normally be circulated within 14 days listing topics discussed and actions agreed and individuals responsible for undertaking those actions. 7.7 An extraordinary meeting may be summoned by the Chair with five working days notice. 7.8 Meetings will be called and conducted in accordance with Standing Orders. 7.9 Minutes of the meeting will be formally recorded and submitted to the BNSSG Healthy Futures Delivery Programme Board. 8.Standing Agenda Items 8.1 Minutes and Actions from previous meetings 8.2 Review of complaints and Serious Incidents 8.3 Review of selected 111 calls 8.4 Review of Clinical Risk Register (5 Stage Review Spreadsheet) 8.5 Safeguarding issues 9.Reporting Arrangements and Relationships 9.1 The NHS 111 Clinical Assurance Committee will report monthly by submissions of minutes to the XXXHealthy Futures Delivery Programme Board 9.2 Quarterly reports will be sent to the Clinical Commissioning Groups, or more frequently by exception. 9.3 The Clinical Governance Lead will attend the NHS xxxxx Regional clinical governance group and provide a report to the Clinical Assurance Committee 14

15 10.Dissolution 10.1 XXX CCG Board can amend, change or dissolve the Committee, in accordance with Standing Orders. 11.Limitation of Authority 11.1 Save as is expressly provided in the Terms of Reference, the NHS 111 Assurance Committee shall have no further power or authority to exercise on behalf of the XXX CCG any of its functions or duties. 12.Review 12.1 These Terms of Reference will be reviewed in annually. Under such circumstances a full amended copy will be circulated to the members of the XXX CCG Board Appendix A - Membership The core membership of the XXX Clinical Governance (CG) Group includes the following: NHS111 Clinical Lead (Chair) Commissioning Lead CCG or CSU Clinical Governance/ Quality Lead Provider Operations Lead Provider Clinical Lead Provider Clinical Governance Lead Provider GP Director Patient Representatives (X2) Local Medical Committee (LMC) Representative Ambulance Trust Representative OOH clinical lead OOH operations lead DoS lead The above regularly attend, in addition depending on the issues under discussion we have asked others to attend on an ad hoc basis, these include: ED Representatives Other local GPs Mental Health Trust Representative Community Health Services Representative Voluntary Sector representatives Other CCG representatives 15

16 4.4 Regional Clinical Governance Group Terms of Reference Regional NHS Purpose Clinical Governance Group Terms of Reference The purpose of the group is to provide overall assurance of the quality and clinical safety of the NHS111 service across the following Clinical Commissioning Groups (CCGs) The xxxx Regional Clinical Governance Group will provide a joint forum between the clinical governance leads, the XXX provider(s), the NHS 111 Contract Board and the wider Urgent Care Networks. 2.0 Objectives The overall objectives of the group are: To contribute to the safety of the NHS 111 service and wider systems ensuring a shared understanding of issues across the XXX area and between providers and commissioners To ensure that shared issues are dealt with collectively and the learning shared across the area To ensure that the combined expertise of the Clinical Governance Leads and the NHS 111 Clinical Leads is brought to bear in finding solutions to these issues To receive assurance by X provider via monthly clinical governance reports that Quality Schedules of the NHS 111 contract are met To monitor the clinical standards against the national (NQRs) and local (LQRs) standards To agree a programme of quality assurance visits Other methods to be agreed as necessary. 3.0 Responsibilities To ensure that clinical governance issues, common across the XXX area, are discussed, that solutions are found and actions agreed are communicated back to the local clinical governance groups and the NHS 111 Contract Board To agree a work programme in relation to quality and safety with the NHS 111 Contract Board and provide reports and other updates to the board To agree with XXX provider remedial actions where clinical standards when not met To provide up to date Clinical Governance status report to the Contract Board highlighting any areas for concern and action taken. 16

17 4.0 Accountability Members of the group will ensure that effective clinical governance arrangements are in place across their area respective organisations and that they are kept informed of any aspects of quality and safety which might affect the safety of the service. The group will: Develop a workstream to ensure that clinical governance and other common issues are identified and addressed across the XXX area Provide a clinical overview and scrutiny of the end to end NHS 111 patient pathway and other governance Ensure that robust processes are in place to recognise, report and investigate serious incidents and that the learning from these is used to improve the service Ensure that assurance processes are in place to update and review the Directory of Service Hold the NHS 111 provider to account for required actions relating to clinical governance and refer to the Contract Board as required. 5.0 Membership: CCG NHS111 Clinical Leads NHS 111 Regional Clinical Governance Lead NHS111 Contract Board members CSCSU Provider Clinical Leads 6.0 Relationships The XXX Clinical Governance Group will report to the NHS 111 Contract Board. The XXX Clinical Governance Group will provide a regular report to the local Clinical Governance groups Through the Regional NHS 111 Clinical Governance Lead, the Regional XXX CG group will provide reports and escalate issues to NHS England. 7.0 Frequency Of Meetings meetings will be held monthly. 8.0 Quoracy the quorum for the meeting will be at least one member from each area. 9.0 Review the Terms of Reference will be reviewed in.. 17

18 4.5 Provider Quality Monitoring Report Template xxxxxxxx CCGs NHS 111 Quality Monitoring Report Template Month Summary The Clinical Governance reporting requirements are set out on the template below and xxxxx are required to report progress on their Clinical Governance arrangements monthly to the xxxxxxxxxxx CCGs Quality Monitoring Review Group. The report will be used to provide assurance to the respective CCG Strategic Quality Committees and Boards that the NHS 111 service is safe, effective and meeting the needs of the patients. Summary: Issues to be considered: Action required: (including any outstanding issues from previous reports) Accountable officer: Author of Report: Date of report: 18

19 2.0 Clinical Effectiveness Clinical Audit OFFICIAL Audits completed No of calls reviewed using the NHS Pathway CQI tool No of Health Advisors reviews carried out No of Clinical Advisers reviews carried out % of calls reviewed per service No of call reviews achieving score >86 Health Advisers Clinical Advisers % call reviews scoring > 86 % of reviews carried out where there was cause for concern Local Quality Reporting audits carried out National Quality Reporting audits carried out Any other audits carried out 19

20 3.0 Outcome of audits Please summarise on the table below the audits carried out & how used to improve the service Audits carried out Issues identified/training needs identified as a result of using the CQI NHS Pathway tool Lessons learned Actions taken to address issues Changes made to improve service 20

21 4.0 Patient Safety - Serious incidents, other incidents, near misses 4.1 Please summarise below the actions taken to address issues identified from these events Event Issues/themes Identified Lessons learned Actions to address issues Changes made to improve service including how lessons learned shared between organisations No of Serious Incidents No of Incidents No of near misses 21

22 4.1.1 Patient, staff and Professional feedback & experience of the service, complaints Health Professional Feedback - reported weekly to CCG lead via log. Prompt feedback to professionals who provide feedback. Analysis of HCP forms to identify trends. Issues/themes Identified Lessons learned Actions to address issues Changes made to improve service & feedback to clinicians/patients/staff No of complaints Healthcare Professional Feedback Patient survey Staff survey 22

23 Forward Plan Report Date due Audit Plan: To include - Audit priorities Timescale for carrying out audit National audits NHS Pathway CQI tool: SI Action Plan CAS Alerts: How many alerts relevant How cascaded How implemented 23

24 Safeguarding Adults & Children: LQR 1 The standard reporting timeframe for Safeguarding indicators are: Reporting Period Annual Report April - March 2 nd week in May 2014 for adults 1 st week of August 2014 for Children Quarter 1 Report (April to June) 1 st week in August 2014 Quarter 2 Report (July to September 2014) data received 1 st week in November 2014 Quarter 3 Report (October-December 2014) data received 1 st week in February 2015 Quarter 4 Report (January-March) data received 1 st week in May 2015 Frequent caller audit: LQR 11 Monthly 24

25 Compliance with CQC standards: LQR 41 Quarterly April, August, December 2014, April 2015 Staff survey: LQR 8 6 monthly NQR 14 Annual assessment of the IG Toolkit Deadline 31 st March each year Information Governance: NQR 15 As part of the Annual report (LQR 39) (refers to reports IG incidents & SIs including action plans) LQR 31 Compliance with the national Patient Safety Agency guidance Annual report: LQR 39 Quarterly July November April August Annual End of May

26 4.6 Audit Report Template Call Centre Audit Report for Clinical Governance Reporting Date: Feb 14 Compiled by: Clinicians Total Calls triaged Across all services: Breakdown Area A Area B Area C Total Number of calls triaged by Clinican by previous month: Total calls audited: Total Pass: Total Fail: Feedback: Total Number of staff Audited: Suggestions for Improvement: 26

27 Monitoring: Retraining: Target Percentage: Actual achieved Percentage: Percentage of staff - suggestion for Improvement: Percentage of Monitoring: Percentage of Retraining: Call Centre Audit Report for Clinical Governance Reporting Date: Compiled by: Call Handler Total Calls Triaged using Pathways Across All Services: Number of calls Breakdown Service A total 27

28 Service B Service C Number of calls total Number of calls total Number of calls Total Number of calls used in Audit Number of calls Total CH calls Audited: Total Pass: Total Fail: Feedback: Total Number of staff Audited: Suggestions for Improvement: Monitoring: Retraining: Target Percentage: 1.00% Actual achieved Percentage: #VALUE! Percentage of staff - suggestion for Improvement: #DIV/0! Percentage of Monitoring: #DIV/0! Percentage of Retraining: #DIV/0! 28

29 4.7 Call and End to End Review Template XXX Clinical Call Audit Call Audit Date: Call ID: Call Theme: Date of Call: Time of Call: Total Length of Call: Age of Patient: Gender of Patient Agencies / Professionals involved: Key Summary of Call: Key Summary from third party: Pathways Used: Disposition Reached (DX Code) 29

30 Was Disposition Accepted? Was the DOS Searched? What Services Returned? Which Service was chosen? OUTCOME Observations: Pros Cons Third Party Response: Recommendations Lessons Learnt: 30

31 Actions Pathways 31

32 4.8 Description of the National Learning Log The NHS 111 National Clinical Leads Group has established a Learning Log of incidents related to NHS 111. The purpose of this is to capture learning from these incidents in a way that will facilitate the dissemination of learning across the service, in order to improve the patient experience and safety. Our focus so far, has been to collect information relating to Serious Incidents through the monthly reports provided by local NHS 111 Clinical Governance Leads and collated by the Regional Leads. These reports are an essential part of the process through which we can support the delivery of a high quality and safe NHS 111 service. The Serious Incident reports and associated Root Cause Analysis investigations are reviewed by the NHS 111 National Medical Advisor and at the national leads meeting for shared dissemination of key learning and escalation of issues. The two attached templates are used by the local and regional leads in this process. 32

33 4.9 Local Clinical Governance Lead Monthly Report Template Site and Provider 111 Monthly Clinical Governance Report Month Prepared by Potential Incidents and Serious Incidents Total potential Serious Incidents this calendar year Closed and actual Closed and not SI Still open Potential Serious Incidents this month Date occurred STEISS Log number and Pathways issues log number Current Status SI upheld RCA received Call Volume No of call reviews No of end to end reviews Performance and Reviews Complaints Health professional forms Compliments 33

34 Details of Incidents, Near Misses & Complaints Type of event (STEISS no.) Detailed description including themes identified Investigation Complete Learning and Improvements made Reported on Issues Log Current Governance Activity and State of Play Description of current governance activity, quality assurance mechanisms, current and future planning 34

35 4.10 Regional Clinical Governance Lead Monthly Report Template Total potential Serious Incidents this calendar year Serious Incidents Closed and actual Closed and not SI Still open Potential Serious Incidents this month Location STEISS Log number and Pathways issues log number Current Status SI upheld RCA received Performance Site Provider Call Volume Call reviews End to end reviews Complaints Professional forms Compliments Regional Total 35

36 4.11 NHS Pathways Intelligent Data Tool The NHS Pathways intelligent tool provides a wealth of local information for clinical governance groups and leads. All providers have access to the tool as do many commissioners, clinical governance leads are encouraged to become familiar with the tool. 36